Living well with persistent pain – a problem solving model

Chronic pain is abnormal. Living well with chronic pain seems a myth, a bit of an impossibility. After all, chronic pain starts with the kind of pain that most people would expect to go away – acute pain. Acute pain is normal and most of us will experience some painful episode today. Acute pain goes away – either by itself, or because we’ve done something to remove the stimulus that triggered the cascade of neurological events that eventually reached the brain that produced the experience of pain.

Because chronic pain begins just like any other pain, and because acute pain generates our attention and stimulates some sort of problem solving process so we can take appropriate action, it makes sense that we apply the same problem solving strategy to the problem of chronic pain. Eccleston and Crombez (2007) proposed that one of the ways we can view the distress, loss of function and reduced quality of life is through a model of “misdirected” problem solving.

Problem solving is often discussed as if the problem exists outside of a context. “Here’s the problem, go solve it” fails to establish the frame of reference – why is it a problem? who has the problem? what contributed to the problem? what resources are available to fix the problem?

One of the major contributions of psychology in the field of pain, particularly a cognitive behavioural model, is helping people view their problem differently. If a situation is viewed differently, the “problem” may go away, or at least be seen as manageable.

BUT, in the case of pain, mostly people start by thinking that pain is something to be cured or fixed, the pain should go away, and life should return to normal. In the case of chronic pain, when the pain persists, the same problem solving strategies that work so well for acute pain begin to get in the way of living. Life becomes a merry-go-round of searching for relief (maybe an explanation, diagnosis, medication, surgery, new treatment), hope being raised, then very often being dashed because nothing has changed.

Eccleston and Crombez describe this cycle in terms of the function of worry. “Where such problem solving leads to success, pain and worry abate. However, when the problem solving attempts fail to find a solution, worry is fueled. A ‘perseverance loop’ is established in which the failure of a solution to the problem of pain amplifies worry. In this loop increased worry functions to strengthen motivation to persevere in solving the problem. Problem formulation becomes narrowed and inflexible, whilst greater effort is employed repeating the same solutions. If on repeated attempts a solution is achieved, again pain and worry will stop. “

Over the past 20 years or so, cognitive behavioural approaches for helping people cope with their ongoing pain have focused on reducing distress and disability by helping people reframe the problem of persistent pain as something that can be managed. This takes the focus off trying to remove the pain, and broadens problem solving so that people begin to look at what else can help them live well.

My research is examining how people who do live well with their pain manage to do so. While the people I’m talking with don’t say no to new treatments, they don’t seem invested in it so that their whole lives are focused on solving the problem of pain. Instead, they seem to view pain as “just another thing” that they deal with while they get on with the real business of living life. Some have found that having chronic pain has enthused them with a new direction in life. Others have a focus on family, or community, or work.

The context of chronic pain matters. It’s the way that the problem of chronic pain is framed that situates and generates the range of problem solving options that are considered. If we ask a person “what’s important in your life”, and see if they’re willing to make room for having pain present while they engage in occupations or activities that allow them to live their values, we offer people a chance to live well with their persistent pain.

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6 comments

Yes, absolutely. I remember a lady I worked with on a condition management programme where we used just this approach, and of course although you don’t mention it here you know as well as I do (better then me!) how difficult emotions and depression can also go with chronic pain, and so these needed attention also. It was a new experience for her to have professionals focus not on the condition but on the rest of her life, and she wasn’t at all sure to start with. Several weeks in she said “I’ve learned I can do things if I approach them differently”, and by the end she was walking up a flight of stairs to meet me, having previously used the lift, and working part time.

Isn’t pain there to warn us that some-thing isn’t right? I have has chronic pain for the last 22 months following TKR and I am due to go on a pain management course next month (at long last) I feel at my wits end..especially when I cannot sleep for the pain.

Hi Elaine
Acute pain which is quite normal is primarily there to alert you to the need to do something to get rid of the threat of damage. In your case though, it sounds like ongoing or chronic pain, which is an abnormal pain response. This kind of pain is caused through (usually) a problem within the pain system, and is something science hasn’t really come to grips with to “cure”. Pain that persists like this means that YOU’RE the one to learn to manage it (become your own pain expert) because you’re the person who knows what it feels like, what helps and what doesn’t, and you’re the person who has to make daily decisions about how to do things. Congratulations on getting into the pain management course – I’m sure you’ll find it helpful.